What is the treatment approach for alcohol dependence?

Treatment of Alcohol Dependence

For alcohol-dependent patients, initiate treatment with benzodiazepines for withdrawal management, followed by acamprosate 666 mg three times daily for relapse prevention, combined with psychosocial support and engagement with Alcoholics Anonymous. 1, 2

Acute Withdrawal Management

Benzodiazepines are the only proven first-line treatment to prevent withdrawal seizures and reduce mortality from delirium tremens. 3, 2

• Start chlordiazepoxide 50-100 mg orally, followed by 25-100 mg every 4-6 hours as needed, with a maximum of 300 mg in the first 24 hours, then taper over 7-10 days 2
• Long-acting benzodiazepines (chlordiazepoxide or diazepam) are preferred for uncomplicated patients, while lorazepam is better for those with hepatic impairment 4, 5
• Limit benzodiazepine treatment to 7-10 days maximum to avoid dependence 2
• Antipsychotics should never be used as stand-alone medications for withdrawal—only as adjuncts to benzodiazepines in severe delirium that hasn't responded to adequate benzodiazepine doses 3
• Anticonvulsants should not be used following an alcohol withdrawal seizure for prevention of further withdrawal seizures 3

Critical Thiamine Administration

• Administer thiamine BEFORE any glucose-containing fluids to prevent precipitating acute Wernicke's encephalopathy 2
• Give oral thiamine to all patients as part of withdrawal management 3
• Patients at high risk (malnourished, severe withdrawal) or with suspected Wernicke's encephalopathy require parenteral thiamine 3

Inpatient vs Outpatient Setting

• Manage patients in an inpatient setting if they have risk factors for severe withdrawal, concurrent serious physical or psychiatric disorders, or lack adequate social support 3

Post-Detoxification Relapse Prevention Pharmacotherapy

Acamprosate is the only medication with sufficient high-quality evidence demonstrating superiority over placebo for maintaining alcohol abstinence in primary care settings. 3, 1

• Start acamprosate 666 mg three times daily, beginning 3-7 days after last alcohol consumption 2
• Naltrexone 50 mg daily is an alternative option that reduces relapse to heavy drinking and drinking frequency, though it doesn't substantially enhance complete abstinence 6, 7
• Before starting naltrexone, ensure patients are opioid-free (including tramadol) for a minimum of 7-10 days to avoid precipitated withdrawal 6
• Never use naltrexone in patients with alcoholic liver disease due to hepatotoxicity risk 1
• Disulfiram can be considered when administration can be monitored and tied to meaningful contingencies, though evidence is mixed 3, 7
• The decision among acamprosate, naltrexone, or disulfiram should consider patient preferences, motivation, and availability 3

Psychosocial Interventions

Psychosocial support should be routinely offered to all alcohol-dependent patients—pharmacotherapy alone is insufficient. 3, 2

• Implement structured psychological interventions using motivational techniques, focusing on accepting lack of control over alcohol, education about dependence, and developing self-control strategies 3, 2
• Cognitive behavioral therapy helps patients develop coping skills and address psychological patterns underlying drinking behavior 1
• Involve family members in treatment when appropriate and offer support to family members in their own right 3

Mutual Help Groups

Actively encourage engagement with Alcoholics Anonymous as it is highly effective and should be routinely recommended as part of comprehensive treatment. 3, 1

• Monitor the impact of attending the group on the patient with alcohol dependence 3
• Family members should also be encouraged to engage with appropriate mutual help groups 3
• Do not rely on AA attendance alone for patients with severe dependence or significant psychiatric comorbidities who require more intensive professional treatment 1

Ongoing Monitoring and Follow-Up

• Schedule regular follow-up appointments every 1-3 months to assess progress and adjust treatment 1
• Continue psychosocial support throughout recovery, not just during initial treatment 2
• Continued engagement with treatment is essential even after achieving initial abstinence, as relapse rates can reach 50% at one year 1

Assessment for Psychiatric Comorbidities

• Screen for anxiety disorders, depression, bipolar disorder, post-traumatic stress disorder, and personality disorders, which are more common in alcohol-dependent patients 3
• Address psychiatric comorbidity concurrently, though definitive diagnosis may require a period of prolonged sobriety 4
• Patients with uncontrolled or unstable psychiatric disorders require specialist referral 3

Common Pitfalls to Avoid

• Never administer glucose-containing fluids before thiamine—this can precipitate acute Wernicke's encephalopathy 2
• Never continue benzodiazepines beyond 10-14 days due to abuse potential 2
• Avoid prescribing addictive substances, including benzodiazepines beyond acute detoxification 4
• Do not underestimate the importance of psychosocial interventions—pharmacotherapy without psychosocial support is inadequate 3, 2
• Ensure compliance-enhancing strategies are implemented for all treatment components, especially medication adherence 6